Primary Care Prior Authorization Waiver (Medicaid & Dual Eligible)
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Implements Rhode Island three-year pilot (Oct 1, 2025–Oct 1, 2028) waiving prior authorization for many medically necessary services ordered by credentialed primary care providers for Medicaid and Dual Eligible members; Medicare benefits excluded.
A three-year pilot (Oct 1, 2025–Oct 1, 2028) prohibits prior authorization for most medically necessary services ordered by PCPs in the scope of their daily practice for Medicaid lines of business.
A specific list of procedure, device and imaging codes will be exempt from prior authorization when ordered by a PCP (ordering PCP NPI required on submission).
Prior authorization remains required for pharmacy products, prescription medications, home care services, LTSS, adult day and assisted living, and certain DME per EOHHS criteria.
Coverage Criteria for PCP Prior Authorization Waiver
PA Waiver Criteria
Prior authorization is waived when ALL of the following are met:
Services billed by PCPs under their PCP NPI have a strong presumption of meeting criteria; listed codes are exempt when the ordering PCP is identified on the submission (include ordering/referring provider and modifier V1 when the billed service is not performed by the PCP).
The PA waiver does not apply to certain categories expressly excluded by state law and regulation. Pharmacy products and prescription medications (for example, diabetic testing supplies, OTC products, and drugs referenced in R.I. Gen. Laws §27-18.9-2) remain subject to existing prior authorization and step therapy requirements and will continue to require PA. Home care, home health, adult day, and private duty nursing services are excluded per Home Care Regulations (210-RICR-20-051.7) and longstanding state policy requiring PA for these services. The exclusion for these categories extends to long-term services and supports (LTSS) and programs where the furnishing/billing provider is the party to request PA. Additionally, certain durable medical equipment (DME) items that require specific EOHHS criteria will continue to require prior authorization unless otherwise specified by EOHHS.
If a service ordered by a PCP is not a covered benefit for the member or is explicitly excluded by regulation, the service will be denied for payment as not covered or not medically necessary. Quantity limits and other benefit-specific exclusions may also trigger a denial. Providers should verify member benefits and applicable regulatory exclusions before submitting claims; when a service is out-of-network, prior authorization remains required to determine coverage and potential patient financial responsibility.
Codes, Thresholds, and Inclusion Criteria
Provider Billing, Submission, and Operational Requirements
Prior Authorization Waived for Listed Codes When Ordered by PCP
Prior authorizations are waived for the listed codes when an eligible Primary Care Provider (PCP) is listed as the ordering provider. The waiver applies only when the ordering PCP is enrolled, credentialed, contracted with Neighborhood, is the member's assigned PCP (or at the same site as the assigned PCP), and has engaged in clinical decision making for the ordered service.
- Eligible PCP must be enrolled, credentialed, and contracted with Neighborhood.
- PCP must be the member's assigned PCP or at the same site as the member's assigned PCP and must have engaged in clinical decision making for the ordered service.
- Waiver applies only to in-network services.
- Examples of included codes: 17999, 43235, 43249, 43251, 43255, 45378, 45380, 45384, 45385, 70486, 70487, 70488, 76380, 70496, 70498, 70544, 70545, 70546, 70551, 70552, 70553, 71275, 71550, 71551, 71552, 72195, 72196, 72197, 74176, 74177, 74178, 74181, 74182, 74183, S8037, 77046, 77047, 77048, 77049, 81229, 81415, 95810, 95811, A4239, B4035, B4150, B4152, B4160, B4161, E0637, E1161, E1232, E1234, E2510, S9127
Claim Submission Requirements
Claims for services eligible for the PCP prior-authorization waiver must include the ordering/referring provider information. When the billed service is not rendered by the PCP, claims must also include modifier V1 to allow for payment. Failure to include the ordering/referring provider or modifier V1 (when applicable) may result in denial or payment delays.
- Include the ordering/referring provider (PCP) NPI on the claim submission.
- When the service is provided by a non-PCP rendering provider, include modifier V1 on the claim.
- If the submission does not show the ordering PCP identification, the claim will not qualify for the PA waiver.
Pharmacy & Medications Excluded
Pharmacy products and prescription medications are excluded from the PA waiver. Prior authorization requirements for pharmacy items (including diabetic testing supplies, OTC products when applicable, and prescription medications) remain in effect as specified by law and policy.
- Pharmacy products and prescription medications remain subject to prior authorization per Section 27-18.9-2 of the General Laws.
- Examples include diabetic testing supplies and other pharmacy-dispensed supplies.
Ordering PCP Identification
Only claims that include the ordering PCP identification as the ordering provider will be exempt from prior authorization for the listed codes. The ordering PCP must be clearly identified on the claim submission and meet the eligibility criteria for the waiver.
- Submission must include the ordering PCP NPI to qualify for the waiver.
- Ordering PCP must meet eligibility: enrolled, credentialed, contracted with Neighborhood and engaged in clinical decision making for the service.
Coverage Exclusions, Quantity Limits, and Out-of-Network Services
Services that are not included in a member's benefits, are excluded by regulation, or exceed quantity limits will be denied even if ordered by a PCP. Prior authorization may still be required for services with specific EOHHS criteria. Out‑of‑network services are not eligible for the waiver and will remain subject to prior authorization and potential member financial responsibility.
- Services not covered under member benefits or excluded by regulation will be denied.
- Quantity limits on services or products still apply and may trigger denials.
- Out-of-network services require prior authorization and may result in member financial responsibility.
- Certain services subject to EOHHS-specific criteria will continue to require prior authorization.
Policy Background and Legislative Context
This policy implements Rhode Island legislation creating a three-year pilot (effective 10/01/2025) to reduce administrative burden by waiving prior authorization for many medically necessary services when ordered by an eligible primary care provider. The waiver is limited to services ordered in the normal course of primary care, provided the PCP is enrolled, credentialed, contracted with Neighborhood, is the member's assigned PCP (or at the same site) and has engaged in clinical decision-making, the service is in-network and covered by the member's benefits, and the service code is included in the pilot list or otherwise meets EOHHS inclusion criteria. EOHHS guidance and criteria (including minimum PCP request counts and approval-rate thresholds) govern which codes may be added or retained and which DME items require continued PA.
Key Definitions
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